title: Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction.
abstract: BACKGROUND
  Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation.
  
  
  METHODS
  We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications.
  
  
  RESULTS
  We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p < 0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p < 0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p < 0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width > 15 cm to be independent predictors of hernia recurrence (HR 7.3; p < 0.001 and HR 2.5; p = 0.028, respectively).
  
  
  CONCLUSIONS
  Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.
authors.affiliation: Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Justin H
authors.initials: JH
authors.lastname: Booth
authors.forename: Patrick B
authors.initials: PB
authors.lastname: Garvey
authors.forename: Donald P
authors.initials: DP
authors.lastname: Baumann
authors.forename: Jesse C
authors.initials: JC
authors.lastname: Selber
authors.forename: Alexander T
authors.initials: AT
authors.lastname: Nguyen
authors.forename: Mark W
authors.initials: MW
authors.lastname: Clemens
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Charles E
authors.initials: CE
authors.lastname: Butler
mesh_terms: D034861:Abdominal Wall / Q000601:surgery*; D058107:Abdominal Wound Closure Techniques / Q000295:instrumentation*; D000328:Adult; D000368:Aged; D000071938:Fasciotomy; D005260:Female; D005500:Follow-Up Studies; D046449:Hernia, Abdominal / Q000517:prevention & control / Q000601:surgery*; D059685:Herniorrhaphy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D055502:Secondary Prevention; D013526:Surgical Mesh; D016896:Treatment Outcome
keywords: AWR; BADM; BMI; CS; HADM; HR; PADM; abdominal wall reconstruction; body mass index; bovine acellular dermal matrix; component separation; hazard ratio; human acellular dermal matrix; porcine acellular dermal matrix